Quality of life and physical performance and activity of breast cancer patients after adjuvant treatments.

OBJECTIVE: The study aimed at investigating the quality of life (QoL) and physical performance and activity, and their interrelations, in Finnish female breast cancer patients shortly after adjuvant treatments. METHODS: A total of 537 disease-free breast cancer survivors aged 35-68 years were surveyed at the beginning of a one year randomized exercise intervention. The patients were interviewed using EORTC QLQ-C30, FACIT-F, RBDI, and WHQ (for vasomotor symptoms) questionnaires. Physical performance was tested by a 2 km walking test. Physical activity was measured by a questionnaire and a prospective two-week diary. Multivariate analysis was used to study the factors associated with QoL. RESULTS: About 26% of the patients were rated as depressed, 20.4% as fatigued, and 82% suffered from menopausal symptoms. The global QoL was lower than in general population (69.4 vs 74.7, p<0.001). About 62% of the walking test results were below the population average. Fatigue (p<0.001), depression (p<0.001), body mass index (p = 0.016) and comorbidity (p = 0.032) impaired, and physical activity (p = 0.003) improved QoL. Physical activity level correlated positively to physical performance (r = -0.274, p<0.0001). CONCLUSIONS: The QoL of the patients shortly after adjuvant treatments was impaired and the physical performance poor as compared to general population. In particular, depression and fatigue were related to impaired QoL. Physical performance and activity level were the only factors that correlated positively to QoL. Thus, physical exercise could be useful in rehabilitation of cancer survivors, especially for depressed and fatigued patients.

Prognostic value of quality of life scores for time to progression (TTP) and overall survival time (OS) in advanced breast cancer.

The purpose of the study was to investigate whether baseline quality of life (QoL) and changes in QoL scores from baseline are prognostic for time to progression (TTP) and/or overall survival (OS) in patients with advanced breast cancer receiving docetaxel (T) or sequential methotrexate and 5-fluorouracil (MF). QoL was assessed at baseline and before each treatment using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30). Survival curves and probabilities were estimated using the Kaplan-Meier technique. The Cox proportional hazards regression model was used for both the univariate and multivariate analyses to explore relationships between baseline QoL variables and TTP, as well as OS. In the univariate analysis, more severe pain and fatigue at baseline were predictive for a shorter OS; global QoL, physical functioning and appetite loss had a borderline significance (P=0.0130 for global QoL; P=0.0256 for physical functioning: P=0.0149 for appetite loss). World Health Organization (WHO) performance status was significantly predictive for OS. In the multivariate analysis, more severe pain at baseline was predictive for a shorter OS. In contrast, baseline QoL had no prognostic value for the duration of TTP. QoL change scores from baseline QoL predicted neither OS nor TTP. Our findings suggest that while QoL measurements are important in evaluating patients' QoL, they have no great importance in predicting primary clinical endpoints such as TTP or OS in advanced breast cancer patients.

Timing of quality of life (QoL) assessments as a source of error in oncological trials.

AIM OF THE STUDY: To produce an empirical estimate of the nature and magnitude of the error produced by incorrect timing quality of life (QoL) measurements in patients receiving chemotherapy. DESIGN: In a multicentre trial, 283 patients were randomized to receive either docetaxel (T) or sequential methotrexate and 5-fluorouracil (MF). The QoL was assessed at baseline and before each treatment using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). The study design was retrospective. Data were analysed using t-tests. RESULTS: Erroneous timing affected the QoL findings in both treatment arms. At baseline, there were statistically significant differences in the MF group on the nausea/vomiting scale, with ill-timed assessment showing more symptoms, and in the T group on the physical functioning scale with ill-timed assessments indicating better QoL. The mean scores of correct vs. incorrect timings over the first 14 cycles showed statistically significant differences on several scales. In the MF group, ill-timed assessments indicated significantly worse physical functioning and global QoL, and significantly more of the following symptoms: fatigue, nausea/vomiting, insomnia, appetite loss, and constipation. In the T group, ill-timed assessment showed better physical functioning, less dyspnoea and more insomnia than correctly timed assessments. The reasons for erroneous timing were not always detectable retrospectively. However, in some cases the MF group, being in standard treatment, seemed to have followed a clinical routine not involving the active participation of the study nurse responsible, whereas patients in the experimental T group were more consistently taken care of by the study nurses. CONCLUSIONS: Incorrect timing of QoL assessments in oncological trials jeopardises both the reliability of the QoL findings within treatment and the validity of QoL outcome comparisons between treatments. This issue should be emphasized in the planning of both the study design and clinical routines.

Cognitive performance and attachment patterns at four years of age in extremely low birth weight infants after early intervention.

This study aims at assessing the effects of an early occupational therapy intervention on the cognitive development and the development of attachment patterns in ELBW infants. The intervention, given weekly at home from six months to 12 months, aimed at supporting parent-child interaction and enhancing motor control and coordination. The study population consisted of 100 ELBW infants matched in pairs in accordance to their pre-perinatal risk scores and allocated successively to intervention or non-intervention groups. Cognitive development was assessed with the Bayley Scales at age two and with the WPPSI at age four. Attachment to primary caregiver was assessed with the Preschool Assessment of Attachment (PAA). Cognitive performance was within age norms in both groups at both ages. Intervention did not show any effect on cognitive performance at the age of two years. At the age of four years, cognitive level was overall, and most notably for verbal performance, higher in the intervention group than in the control group. There was an over-representation of the so-called atypical attachment patterns (those not fitting the normative A, B, or C categories) in the control group. The results are discussed in terms of finding more global ways to support the development of at risk pre-term children.

Cognitive development, temperament and behavior at 2 years as indicative of language development at 4 years in pre-term infants.

This study focuses on the early temperamental (TTQ = toddler temperament questionnaire), behavioral (IBR = infant behavior record), and cognitive precursors of impaired language functioning in preschool-age pre-terms infants. The study group consisted of 63 pre-term infants with a mean birth weight of 1246 +/- 437 g born in 1989-1991 in the University Central Hospital of Helsinki. Children with major disabilities (CP or mental retardation) were excluded. At the age of 4 years, 22% showed impaired language function. Logistic regression analysis showed that the Bayley MDI score was the best predictor in identifying an increased risk for language impairment. Behavioral characteristics were more strongly associated with subsequent language impairment than temperament.

Quality of life in patients with metastatic breast cancer receiving either docetaxel or sequential methotrexate and 5-fluorouracil. A multicentre randomised phase III trial by the Scandinavian breast group.

The purpose of this study was to evaluate the effects of two alternative chemotherapy regimes on the quality of life (QoL) of patients with advanced breast cancer. In a multicentre trial, 283 patients were randomised to receive either docetaxel (T) or sequential methotrexate and 5-fluorouracil (MF). QoL was assessed at baseline and before each treatment using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30). Initial compliance in the QoL study was 96% and the overall compliance 82%. QoL data were available for 245 patients (T 130 and 115 MF). Both treatment groups showed some improvement in emotional functioning during treatment, with a significant difference favouring the MF group at treatment cycles 5 and 6. In the T group, the scores on the other functional scales remained stable throughout the first six cycles. There were significant differences favouring the MF group on the social functioning scale at treatment cycle 6 and on the Global QoL scale at treatment cycles 5 and 6. On most symptom and single-item scales there were no statistically significant differences between the groups. However, at baseline, the T patients reported more appetite loss, at treatment cycles 2-4, the MF patients reported more nausea/vomiting, and at treatment cycle 6, the T patients reported more symptoms of fatigue, dyspnoea and insomnia. There were no statistically significant differences between the groups in the mean change scores of the functional and symptom scales. Interindividual variance was, however, larger in the T group. Differences in QoL between the two treatment groups were minor. Hence, given the expectancy of comparable QoL outcomes, the choice of treatment should be made on the basis of the expected clinical effect.

Recent European research on older drivers.

This paper discusses European research on older drivers published since 1985. It is not intended to be an exhaustive review; rather, the focus is on those issues that have been most topical during the past fifteen years. First, the paper deals with general efforts to integrate ageing into transport policy design. The emphasis is placed on differences in the European and American perspectives and discourse. Second, some research issues that have been topical in the European research agenda are reviewed, with a few examples of each. Third, a brief outline is given of newly emerging research issues of importance.

Why do older drivers give up driving?

All Finnish license holders aged 70 years (from the cohort born in 1922) who did not renew their driver license, and a corresponding comparison group among those who did renew their license, were contacted by a mail survey. They were asked about their reasons to continue or to stop driving, about their current living conditions and health status, and about some aspects of their driving behavior. The reasons to stop or to continue driving were different for men and women. Male drivers considered more frequently than female drivers the use of private car a necessity. Male respondents who did not renew their license (ex-drivers) were less healthy than those who did renew their license (drivers). The most frequently indicated reason to stop driving among men was deteriorated health. However, only 6.9% of the ex-drivers had received professional advice to stop driving. For most of these cases, this advice had been given by the physician responsible for the treatment of their main illness. The change in health condition was related to a shift in driving activity: those still driving were in best health, followed by those ex-drivers who stopped driving at the age of 70 years, while those who had stopped driving at an earlier age had the highest number of illnesses and had most frequently experienced a deterioration of their health status during the last year. Both male and female ex-drivers reported more feelings of stress in traffic and more frequent avoidance of certain traffic situations than drivers. Women reported more frequently traffic-related stress and avoidance than men as both drivers and ex-drivers.

Impairments of some cognitive functions are common in crash-involved older drivers.

The relationship between limitations in different cognitive functions, measured with a neuropsychological test battery, and moving traffic violations among older drivers was investigated. Thirty-seven drivers aged 65 years or more, with temporarily suspended driving licenses (suspended drivers) were identified 23 were crash-involved and 14 were not. When compared to 31 controls with clean driving records, crash-involved suspended drivers performed less well on tests of visuoconstructive ability (p = 0.008), psychomotor speed (p = 0.019) and visuospatial memory (p = 0.036). Non-crash-involved suspended drivers did not differ from controls. A combination of three tests (of visuoconstructive ability, visuospatial memory and verbal episodic memory) succeeded in correctly classifying 65.2% of the crash-involved suspended drivers. The results support the idea of cognitive decrements as an important causal factor in crashes of older drivers.

Arthrogryposis multiplex congenita: perinatal and electromyographic findings, disability, and psychosocial outcome.

Fifty-two patients with arthrogryposis multiplex congenita were followed up for 1 to 36 years. There were six twin pregnancies, and delivery was complicated by breech position in 16 cases. In 19 cases the cause was atrophy of the alpha motoneurons of the spinal cord, detected by electromyography. Six patients did not achieve walking ability. Severe disability for other reasons was noted in two patients who had bilateral rigid extension contractures of the elbows and in six patients whose spinal deformities interfered with the balance of the trunk. Treatment of flexion contractures of the hips and knees seemed to be important in case it promotes the walking ability. Spinal deformities interfering with the balance of the trunk should be treated operatively. Restoration of elbow flexion was the main goal in operative treatment of the upper extremities. The intelligence of the patients was slightly above normal. The psychological analysis revealed significant diverging features compared with average population in testing situation. Socially the patients seemed to cope well.

Dementia and driving: an attempt at consensus.

The number of older drivers in Sweden will be rapidly increasing during the next decades. A possible relationship exists between the increased relative crash risk of older drivers and the prevalence of age-related diseases such as dementia. However, a clear-cut policy for evaluating driving competence in demented persons is still lacking. In recognition of this fact, the Swedish National Road Administration invited a group of researchers to formulate a consensus on the issue of driving and dementia. This consensus document is aimed at providing primary care physicians with practical advice concerning the assessment of cognitive status in relation to driving. Suggestions are based on a review of existing research and discuss the use of general and driving-specific sources of information available to the physician. Consensus was reached on the statement that a diagnosis of moderate to severe dementia precludes driving and that certain individuals with mild dementia should be considered for a specialized assessment of their driving competence.

Medical screening of older drivers as a traffic safety measure--a comparative Finnish-Swedish evaluation study.

OBJECTIVES: To evaluate the safety effect of age-related medical screening of older drivers by comparing the licensing laws and accident rates for older road users in Finland and Sweden. DESIGN: Post hoc comparison of Sweden and Finland with respect to three different risk variables. SETTING: Nationwide Swedish and Finnish accident, licensing, and population data from the year 1990 were provided for the present study by the local authorities responsible for tabulating these data. PARTICIPANTS: Data about all citizens born in 1960 or earlier, i.e., aged 30 years or more in the year of measurement, are included. MEASUREMENTS: Rates of police-reported private car accidents leading to personal injury, fatality rates of private car drivers and passengers, and fatality rates of unprotected road users. RESULTS: The age-related variation in private car accident and private car fatality trends was similar in both countries. Fatalities among unprotected road users (i.e., pedestrians, cyclists, and mopedists) increased more sharply with age among the older Finnish population than among the Swedish population. CONCLUSION: We found no safety-related reasons to implement age-related medical screening of older drivers of the kind practiced in Finland. On the contrary, by producing a modal shift toward a more risky mode of travelling, this screening may indirectly lead to higher fatality rates among older road users.

Driver licenses as a measure of older drivers' exposure: a methodological note.

The limitations of the number of driver licenses as an estimate of driving exposure were demonstrated by comparing Finnish and Swedish driver licensing practices, licensing rates and accident rates of older drivers. In Sweden, there is no screening for older license holders, and most of them keep their licenses for life. In Finland, there is a heavy and costly medico-legal control system for older license holders, leading to both screening and self-screening. Consequently, in the two countries, the numbers of driver licenses do not reflect the numbers of active older drivers in the same manner. This difference affects the comparative accident statistics: with respect to population, Finland and Sweden have similar age trends in accidents risk, but with respect to the number of driver licenses, the Finnish older drivers seem to have a higher risk of accident than the Swedish ones. It is concluded that if group comparisons of accident risk are presented using the number of driver licenses as an estimate of exposure, the licensing legislation and practice should affect all the groups in an identical manner for the comparison to be valid.

Aging and fatal accidents in male and female drivers.

The effect of aging on fatal accident characteristics of male and female drivers was investigated using Finnish fatal-accident case study material from the period 1984-1990. Age-bound changes in accident characteristics (e.g., increase of at-fault accidents and of collisions in intersections) appeared in both sexes but seemed to affect female drivers at an earlier age and to a higher degree. When the sexes differed in accident characteristics, those of female drivers were more like the ones typically found in older drivers. The female drivers were also both quantitatively and qualitatively less experienced as drivers than their male counterparts. Thus, the lower resistance of women to the effects of aging on driving may be explained by their lower skill level. In future cohorts of old drivers, decrease of sex differences in experience will presumably attenuate the sex differences in accident characteristics.

Compensation in older drivers as reflected in their fatal accidents.

To estimate safety effects of compensatory changes in the driving behavior of older drivers (age 65+), their fatal accidents were compared with those of young and middle-aged drivers (26-40 years) in different situations. The starting point of the present study was that without compensation for age-bound functional deficits, more difficult conditions would also be more dangerous, but that successful compensation could reduce the increased risk. The results obtained support this conclusion. Relatively fewer accidents of older drivers occurred under difficult conditions than in the comparison group, i.e. the older drivers had fewer accidents at nighttime and under bad weather and road-surface conditions. Older drivers were also less often in a hurry, alcohol intoxicated, or distracted by nondriving activities than the drivers of the comparison group. The probability of being the legally responsible party was not related to these external and internal factors among older drivers, but was in the comparison group.

Fatal accidents of older drivers.

Fatal accidents of drivers aged 65 or more in Finland in 1984-1989 were compared with those of the statistically safest age group of 26-40 with special emphasis on self-caused accidents. The basic material consisted of 769 multidisciplinary investigated traffic accidents. Older drivers had an overall responsibility ratio [(single + guilty)/total] of .89 versus .61 for the comparison group; in collisions between vehicles this ratio was .87 versus .50. The number of accidents per driver's license increased with age in old drivers. Accidents caused by older drivers were different from those of the comparison group. Old drivers typically collided in an intersection with a crossing vehicle, which they did not notice at all, or saw so late that they did not have enough time to try an avoiding maneuver. Accident characteristics and their implications for safety research and countermeasures are discussed.